Assent

ASSENT TO PARTICIPATE IN RESEARCH
The University of Mississippi Medical Center
Stomach infections in kids living in Mississippi
_____________________________________________________
Dr. Hobbs is doing a research study to try and find out why kids who are living in
Mississippi have infections in their stomachs. You are being asked if you want to be in this
research study because you live in Mississippi and you are a kid.
If you decide that you want to be in this research study, this is what will happen to you:
1.

Dr. Hobbs will ask you and one of your parents to collect some of your stool (poop,
Number 2) in a special container and return it to us. This only takes a few minutes
at home, but you will do it 3 times.

2.

Some of the information that the school nurse collects on you - like your age,
weight, height, blood count and lead levels- will be shared with Dr. Hobbs.

3.

We will collect a drop of your blood on a piece of paper

Sometimes kids might feel embarrassed about collecting and dropping off a stool sample.
We will give you a special bag for the container and have a special drop off spot to help
make it not so embarrassing.
You don’t have to be in this research study if you don’t want to. Nobody will be mad at you
if you say no. Even if you say yes now and change your mind after you start doing this
study, you can stop and no one will be mad.
Be sure to ask Dr. Hobbs or the nurse to tell you more about anything that you don’t
understand.



Yes, I will be in this research study.



No, I don’t want to do this.

_____________________________________________
Write your name on this line

____________
Date

University of Mississippi Medical Center
FWA00003630

Protocol: 2016-0111
Approved: 05/21/2019
Expires: 05/19/2020